BACKFLOWCERTIFICATION OF RE-CLAIMED WATER SYSTEMS gA RObj* CROSS CONNECTION SPECIALISTS
BACKFLOW PREVENTION VALVE EXPERT
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS_,,
�j INSTALLATION -REPAIRS -TESTING -CERTIFICATION
•s'M
BACKFLOW PREVENTION
SPECIALISTS, INC,
LICENSED CONTRACTOR C.C.L.# 427328
CALIFORNIA (800) 464 -FLOW (3569)
(408) 269-2600
3750-E CHARTER PARK DR., SAN JOSE CA 95136.1356
3608 FERNV400D ST., SAN MATEO CA 94403
FAX (408) 269-2650
VACUUM BREAKERS -
•
SERVICE ADDRESS 10251 Torte
Ave
MAILING ADDRESS Civic Park -G, LLC
20725 Valley Green Dr., Ste. 100
Cupertino, CA 95014
MANUFACTURER MODELNUMBER TYPE
Wilkins 3-25 po
CONTACT LCI
TEL# 262-141
SIZE
3"
SERIAL NUMBER
L207S2
INTERNAL ❑ TAG LOCATION OF DEVICE mtr# 20956000 mtr# 36663593 domestic water
EXTERNAL
Tooj ' Gpp-/ 5
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX 9 PASS qL FAIL❑ -
THE ABOVE RE
INITIAL TEST BY
• REPAIRED BY
ERTIFIED TESTER NO. 10466 DATE 11-22-04
MO. DAY YR.
,ATE I
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.
I:
REDUCED PRESSURE DEVICES
PRESSURE TYPE '
DOUBLE CHECK VALVES
VACUUM BREAKERS -
RPP VALVES
DIFFERENTIAL
CHECK VALVE
CHECK VALVE
PRESSURE/RELIEF
VALVE
AIR INLET
CHECK VALVE
N0.1
N0.2
CLO D TIGHT �,
CLOSED TIGHT �Q
22 �
OPENED AT,LBS.
OPENED AT _ LBS
CLOSED TIGHT ❑
INITIAL
# lbs. 4.D
Ies.
#LBS
$ LBS.
TEST
OPENED UNDER 2.0
OPENED UNDER 1.0
LEAKED ❑
LEAKED ❑
OR DID NOT OPEN ❑
OR DID NOT OPEN ❑
LEAKED ❑
REPAIRS
AND
MATERIALS
USED
FINAL
CLOSED TIGHT C1
CLOSED TIGHT ❑
CLOSED TIGHT
OPENED AT_LBS
OPENED AT_LOS
TEST
$LBS
$LBS
#USS
THE ABOVE RE
INITIAL TEST BY
• REPAIRED BY
ERTIFIED TESTER NO. 10466 DATE 11-22-04
MO. DAY YR.
,ATE I
FINAL TEST BY CERTIFIED TESTER NO. DATE
MO. DAY YR.
I:
CERTIFICATION OF RE-CLAIMED WATER SYSTEMS ��d°M CROSS CONNECTION SPECIALISTS
CERTIFIED CROSS CONNECTION CONTROL CONSULTANTS BACKFLOW PREVENTION VALVE EXPERT
INSTALLATION -REPAIRS -TESTING -CERTIFICATION
BACKFLOW PREVENTION SPECIALISbTS,NC,
LICENSED CONTRACTOR C.C.L.# 427328 CALIFORNIA (800) 464 -FLOW (3569) I
3750-E CHARTER PARK DR., SAN JOSE CA 95136-1356 (408)269-2d.00 DEC 0 rd 'L004
3608 FERNWOOD ST.. SAN MATEO CA 94403 FAX (408) 269-2650
F-1 L
SERVICE ADDRESS 10251 Torre Ave., Cupertino/X-Rodrigues Ave.
MAILING ADDRESS Civic Park -G, LLC CONTACT Leaundra
20725 Valley Green Dr., Ste. 100 TEL# 262-1418
Cupertino, CA 95014
MANUFACTURER MODEL NUMBER TYPE SIZE SERIAL NUMBER
Wilkins '475 Y(— N 2" ' W187304
INTERNAL ❑ TAG LOCATION OF DEVICE Intr# 50014731 irrigation
EXTERNAL
IF DEVICE IS ANEW INSTALLATION PLEASE CHECK THIS BOX 01� PAS8�$ FAIL❑
THE ABOVE REPORT IS CERTIFIED TORE TRUE
INITIAL TEST BY
• REPAIRED BY
FINAL TEST BY
CERTIFIED TESTER NO. 10466 DATE 11-22-04
DATE
CERTIFIED TESTER NO. DATE
MO. DAY YR.
MO. DAY YR.
REDUCED PRESSURE DEVICES
PRESSURE TYPE
DOUBLE CHECK VALVES
VACUUM BREAKERS
RPP VALVES
DIFFERENTIAL
CHECK VALVE
CHECKVALVE
PRESSURE/RELIEF
VALVE
AIR INLET
CHECKVALVE
NO.1
NO.2
CLOSED TIGHT`
CLOSED TIGHT
OPENED AT LBS.
OPENEDAT_LBS
CLOSED TIGHT ❑
INITIAL
#lbs.
lbs.
*LBS
#LBS.
TEST
OPENED UNDER 2.0
OPENED UNDER 1.0
LEAKED ❑
LEAKED ❑
OR DID NOT OPEN ❑
OR DID NOT OPEN ❑
LEAKED ❑
REPAIRS
AND
-
MATERIALS
USED
FINAL
CLOSED TIGHT ❑
CLOSED TIGHT ❑
CLOSED TIGHT ❑
OPENED AT LBS
OPENED AT LBS
TEST
i LBS
#LBS
_
_
# LBS
THE ABOVE REPORT IS CERTIFIED TORE TRUE
INITIAL TEST BY
• REPAIRED BY
FINAL TEST BY
CERTIFIED TESTER NO. 10466 DATE 11-22-04
DATE
CERTIFIED TESTER NO. DATE
MO. DAY YR.
MO. DAY YR.